Buprenorphine: Difference between revisions
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==Background== |
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* Recommended as first-line treatment for [[opioid use disorder]] |
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* Typically coformulated with naloxone (trade name Suboxone) at a dose of 2 mg buprenorphine to 0.5 mg naloxone |
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* Buprenorphine is partial mu-opioid receptor agonist |
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* Theoretical ceiling effect |
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* Strong receptor affinity, displaces other opioids |
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*Recommended as first-line treatment for [[opioid use disorder]] in Canadian guidelines |
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== Dosing == |
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*Typically coformulated with [[naloxone]] (trade name Suboxone) at a dose of 2 mg buprenorphine to 0.5 mg [[naloxone]] |
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=== Full Start === |
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*Buprenorphine is partial μ-opioid receptor agonist |
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* It's use can precipitate withdrawal, so wait 12-24h after short-acting opioids, 18-36h after long-acting, or after tapering methadone, before starting buprenorphine |
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*Strong receptor affinity, displaces other opioids and can precipitate withdrawal |
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* Day 1: Ensure they are in mild withdrawal ([[COWS]] ≥12), then give 4mg, wait a few hours, give another 4mg |
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*Theoretical ceiling effect on side effects |
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* Day 2: 12mg |
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* Day 3: 16mg; discharge and refer to Addictions clinic |
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==Dosing== |
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== Further Reading == |
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===Standard Induction Protocol=== |
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* [https://www.porticonetwork.ca/documents/204049/0/Opioids+enabler+PDF/f67d20ec-3666-489a-a2dc-ebb5d63225f6 Opioid Enabler] |
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* Hämmig R ''et al.'' [https://dx.doi.org/10.2147%2FSAR.S109919 Use of microdoses for induction of buprenorphine treatment with overlapping full opioid agonist use: the Bernese method]. ''Subst Abuse Rehabil''. 2016; 7: 99–105. |
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*It's use can precipitate withdrawal, so wait 12-24h after short-acting opioids, 18-36h after long-acting, or after tapering methadone, before starting buprenorphine |
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{| class="wikitable" |
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!Day!!Buprenorphine!!Opioid |
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|- |
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|—||—||stop to ensure withdrawal ([[COWS]] ≥12) |
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|- |
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|1||2 to 4 mg + 2 mg q1h prn (max 12 mg)||none |
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|- |
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|2||dose from yesterday + 2 mg q1h prn (max 16 mg)||none |
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|} |
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===Microdosing Protocols=== |
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*Suboxone combined with a short-acting opioid such as [[hydromorphone]] |
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*In general, all opioids can be stopped once at a dose of buprenorphine 12 mg daily |
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====Short-Acting Opioids (Daily Dosing)==== |
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{| class="wikitable" |
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!Day!!Burprenorphine!!Short-acting opioid |
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|- |
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|1||0.5 mg||maintain |
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|- |
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|2||1 mg||maintain |
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|- |
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|3||1.5 mg||maintain |
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|- |
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|4||2 mg||maintain |
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|- |
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|5||2.5 mg||maintain |
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|- |
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|6||3 mg||maintain |
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|- |
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|7||4 mg + 2 mg q1h prn (max 12 mg)||stop |
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|} |
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==== Short-Acting Opioids (Twice-Daily Dosing) ==== |
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{| class="wikitable" |
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!Day!!Burprenorphine!!Short-acting opioid |
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|- |
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|1||0.5 mg daily||maintain |
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|- |
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|2||0.5 mg bid||maintain |
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|- |
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|3||1 mg bid||maintain |
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|- |
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|4||2 mg bid + 2 mg q1h prn (maximum of 12 mg)||stop |
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|} |
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==== Long-Acting Opioids (Daily Dosing) ==== |
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* Including fentanyl, fentanyl patches, and methadone |
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{| class="wikitable" |
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!Day!!Burprenorphine!!Short-acting opioid |
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|- |
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|1||0.5 mg||maintain |
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|- |
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|2||1 mg||maintain |
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|- |
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|3||1.5 mg||maintain |
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|- |
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|4||2 mg||maintain |
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|- |
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|5||2.5 mg||maintain |
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|- |
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|6||3 mg||maintain |
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|- |
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|7||4 mg||maintain long-acting; stop any short-acting opioids |
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|- |
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|8 |
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|5 mg |
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|maintain |
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|- |
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|9 |
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|6 mg |
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|maintain |
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|- |
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|10 |
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|7 mg |
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|maintain |
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|- |
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|11 |
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|8 mg |
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|maintain |
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|12 |
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|10 mg |
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|maintain |
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|13 |
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|12 mg |
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|maintain |
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|14 |
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|12 mg |
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|stop all remaining opioids |
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|} |
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====Long-Acting Opioids (Twice-Daily Dosing)==== |
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{| class="wikitable" |
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!Day!!Burprenorphine!!Short-acting opioid |
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|- |
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|1||0.5 mg daily||maintain |
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|- |
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|2||0.5 mg bid||maintain |
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|- |
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|3||1 mg bid||maintain |
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|- |
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|4||2 mg bid||maintain long-acting, stop any short-acting opioids |
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|- |
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|5 |
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|3 mg bid |
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|maintain |
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|- |
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|6 |
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|4 mg bid |
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|maintain |
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|- |
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|7 |
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|12 mg + 2 mg q1h prn (maximum 16 mg) |
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|stop all remaining opioids |
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|} |
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=== Extended-Release Monthly Injection (BUP-XR) === |
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* Consider once stabilized on 8 to 24 mg buprenorphine for at least 7 days |
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* 300 mg SC monthly for the first 2 months, followed by 100 mg SC monthly maintenance |
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=== Perioperative Management === |
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*Ideally, continue buprenorphine treatment without interruption and use higher doses of opioid analgesia |
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*If going to hold buprenorphine for surgery: |
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**Consider tapering to 12 mg daily 2 to 3 days prior to surgery, or as low as 8 mg if a large or painful surgery |
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**For the surgery itself, use NSAIDs, [[fentanyl]], regional blocks, adjuncts, and non-pharmacologic options |
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**Post-op, resume original dose as soon as possible, possibly split bid to tid to optimize for pain control, and continue non-buprenorphine pain management, including full agonist opioids if needed |
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==Further Reading== |
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*Management of opioid use disorders: a national clinical practice guideline. ''CMAJ''. 2018;190(9):E247-E257. doi: [https://doi.org/10.1503/cmaj.170958 10.1503/cmaj.170958] |
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*[https://www.porticonetwork.ca/documents/204049/0/Opioids+enabler+PDF/f67d20ec-3666-489a-a2dc-ebb5d63225f6 Opioid Enabler] cheat sheet from Portico Network |
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*Use of microdoses for induction of buprenorphine treatment with overlapping full opioid agonist use: the Bernese method. ''Subst Abuse Rehabil''. 2016; 7: 99–105. doi: [https://doi.org/10.2147/SAR.S109919 10.2147/SAR.S109919] |
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*Buprenorphine/Naloxone Microdosing: The Bernese Method. A Brief Summary for Primary Care Clinicians. 2019. Available at https://www.metaphi.ca/wp-content/uploads/Guide_Microdosing.pdf |
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[[Category:Opioid substitution therapy]] |
[[Category:Opioid substitution therapy]] |
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Latest revision as of 21:22, 12 March 2023
Background
- Recommended as first-line treatment for opioid use disorder in Canadian guidelines
- Typically coformulated with naloxone (trade name Suboxone) at a dose of 2 mg buprenorphine to 0.5 mg naloxone
- Buprenorphine is partial μ-opioid receptor agonist
- Strong receptor affinity, displaces other opioids and can precipitate withdrawal
- Theoretical ceiling effect on side effects
Dosing
Standard Induction Protocol
- It's use can precipitate withdrawal, so wait 12-24h after short-acting opioids, 18-36h after long-acting, or after tapering methadone, before starting buprenorphine
| Day | Buprenorphine | Opioid |
|---|---|---|
| — | — | stop to ensure withdrawal (COWS ≥12) |
| 1 | 2 to 4 mg + 2 mg q1h prn (max 12 mg) | none |
| 2 | dose from yesterday + 2 mg q1h prn (max 16 mg) | none |
Microdosing Protocols
- Suboxone combined with a short-acting opioid such as hydromorphone
- In general, all opioids can be stopped once at a dose of buprenorphine 12 mg daily
Short-Acting Opioids (Daily Dosing)
| Day | Burprenorphine | Short-acting opioid |
|---|---|---|
| 1 | 0.5 mg | maintain |
| 2 | 1 mg | maintain |
| 3 | 1.5 mg | maintain |
| 4 | 2 mg | maintain |
| 5 | 2.5 mg | maintain |
| 6 | 3 mg | maintain |
| 7 | 4 mg + 2 mg q1h prn (max 12 mg) | stop |
Short-Acting Opioids (Twice-Daily Dosing)
| Day | Burprenorphine | Short-acting opioid |
|---|---|---|
| 1 | 0.5 mg daily | maintain |
| 2 | 0.5 mg bid | maintain |
| 3 | 1 mg bid | maintain |
| 4 | 2 mg bid + 2 mg q1h prn (maximum of 12 mg) | stop |
Long-Acting Opioids (Daily Dosing)
- Including fentanyl, fentanyl patches, and methadone
| Day | Burprenorphine | Short-acting opioid |
|---|---|---|
| 1 | 0.5 mg | maintain |
| 2 | 1 mg | maintain |
| 3 | 1.5 mg | maintain |
| 4 | 2 mg | maintain |
| 5 | 2.5 mg | maintain |
| 6 | 3 mg | maintain |
| 7 | 4 mg | maintain long-acting; stop any short-acting opioids |
| 8 | 5 mg | maintain |
| 9 | 6 mg | maintain |
| 10 | 7 mg | maintain |
| 11 | 8 mg | maintain |
| 12 | 10 mg | maintain |
| 13 | 12 mg | maintain |
| 14 | 12 mg | stop all remaining opioids |
Long-Acting Opioids (Twice-Daily Dosing)
| Day | Burprenorphine | Short-acting opioid |
|---|---|---|
| 1 | 0.5 mg daily | maintain |
| 2 | 0.5 mg bid | maintain |
| 3 | 1 mg bid | maintain |
| 4 | 2 mg bid | maintain long-acting, stop any short-acting opioids |
| 5 | 3 mg bid | maintain |
| 6 | 4 mg bid | maintain |
| 7 | 12 mg + 2 mg q1h prn (maximum 16 mg) | stop all remaining opioids |
Extended-Release Monthly Injection (BUP-XR)
- Consider once stabilized on 8 to 24 mg buprenorphine for at least 7 days
- 300 mg SC monthly for the first 2 months, followed by 100 mg SC monthly maintenance
Perioperative Management
- Ideally, continue buprenorphine treatment without interruption and use higher doses of opioid analgesia
- If going to hold buprenorphine for surgery:
- Consider tapering to 12 mg daily 2 to 3 days prior to surgery, or as low as 8 mg if a large or painful surgery
- For the surgery itself, use NSAIDs, fentanyl, regional blocks, adjuncts, and non-pharmacologic options
- Post-op, resume original dose as soon as possible, possibly split bid to tid to optimize for pain control, and continue non-buprenorphine pain management, including full agonist opioids if needed
Further Reading
- Management of opioid use disorders: a national clinical practice guideline. CMAJ. 2018;190(9):E247-E257. doi: 10.1503/cmaj.170958
- Opioid Enabler cheat sheet from Portico Network
- Use of microdoses for induction of buprenorphine treatment with overlapping full opioid agonist use: the Bernese method. Subst Abuse Rehabil. 2016; 7: 99–105. doi: 10.2147/SAR.S109919
- Buprenorphine/Naloxone Microdosing: The Bernese Method. A Brief Summary for Primary Care Clinicians. 2019. Available at https://www.metaphi.ca/wp-content/uploads/Guide_Microdosing.pdf
